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Unformatted text preview: Personality Disorders
and Forensic Psychiatry
and
Department of Psychiatry
1st Faculty of Medicine
Charles University, Prague
Head: Prof. MUDr. Jiří Raboch, DrSc. Disorders of Adult Personality
and Behaviour (F60-F69)
and
F60
F61
F62
F63
F64
F65
F66
F68
F69 Specific personality disorders Mixed and other personality disorders Enduring personality changes, not attributable to brain damage and disease Habit and impulse disorders Gender identity disorders Disorders of sexual preference Psychological and behavioural disorders associated with sexual development and orientation Other disorders of adult personality and behaviour Unspecified disorder of adult personality and behaviour F60 Specific Personality Disorders
F60
F60
F60.0
F60.1
F60.2
F60.3
F60.4
F60.5
F60.6
F60.7
F60.8
F60.9 Specific personality disorders Paranoid personality disorder Schizoid personality disorder Dissocial personality disorder Emotionally unstable personality disorder Histrionic personality disorder Anankastic personality disorder Anxious (avoidant) personality disorder Dependent personality disorder Other specific personality disorders Personality disorder, unspecified F60 Specific Personality Disorders
F60 Specific personality disorders • severe disturbances in the personality and behavioural tendencies of the individual
• not directly resulting from disease, damage, or other insult to the brain, or from another psychiatric disorder
• usually involving several areas of the personality
• nearly always associated with considerable personal distress and social disruption
• usually manifest since childhood or adolescence and continuing throughout adulthood. F60 Specific Personality Disorders
F60 Personality disorder is persistent and appears already within late childhood and adolescence being fully manifested in adulthood (diagnosing after the age of 16­17 years)
The disorder is usually associated with significant problems in occupational and social performance
Causes of personality disorders are mostly genetic though the influence of upbringing, parent­child relationship and social environment play also their roles. F60.0 Paranoid Personality
Disorder
Disorder Paranoid personality disorder ­ characterized by excessive sensitiveness to setbacks, persistent refusal to forgive insults and slights, suspiciousness, tendencies to misconstrue the neutral or friendly actions of others as hostile or contemptuous, suspiciousness concerning fidelity of sexual partner, tendencies to experience excessive self­importance and preoccupation with unsubstantiated conspiratorial explanations of events.
Personality (disorder): •
•
•
•
• expansive paranoid
fanatic
querulant
paranoid
sensitive paranoid F60.1 Schizoid Personality Disorder
F60.1 Schizoid personality disorder ­ few activities provide pleasure, emotional coldness, limited capacity to express either warm or hostile feelings with indifference to either praise or criticism, little interest in having sexual experiences with another person, preference for solitary activities, excessive preoccupation with fantasy and introspection, lack of close friends and marked insensitivity to prevailing social norms and conventions. F60.2 Dissocial Personality
Disorder
Disorder Dissocial personality disorder: gross disparity between behaviour and the prevailing social norms
a callous disregard for the feelings of others, incapacity to maintain enduring relationships, gross attitude of irresponsibility
• very low tolerance to frustration, a low threshold for discharge of aggression and violence
• incapacity to experience guilt and to profit from experience including punishment
• a tendency to blame others, or to offer plausible rationalizations for the behaviour bringing the patient into conflict with society
•
• Personality (disorder): •
•
•
•
• amoral
antisocial
asocial
psychopathic
sociopathic F60.3 Emotionally Unstable
Personality Disorder
Personality Emotionally unstable personality disorder: • characterized by a definite tendency to act impulsively without consideration of the consequences, together with affective instability
• outbursts of anger may lead to violence, particularly in response to criticism (impulsive type) Two types may be distinguished: • impulsive type ­ characterized predominantly by emotional instability and lack of impulse control,
• borderline type ­ characterized in addition by disturbances in self­image, aims, and internal preferences, by chronic feelings of emptiness, by intense and unstable interpersonal relationships, and by a tendency to self­
destructive behaviour, including suicide gestures and attempts Personality (disorder): •
•
• aggressive
borderline
explosive F60.4 Histrionic Personality
Disorder
Disorder Histrionic personality disorder: • self­dramatization, pseudologia phantastica, exaggerated expression of emotions, enhanced suggestibility, shallow and labile affectivity, continual seeking for excitement, appreciation by others, and activities in which the patient is the centre of attention, over­concern with physical attractiveness together with inappropriate seductiveness, egocentricity, manipulative behaviour Personality (disorder):
• hysterical
• psychoinfantile F60.5 Anankastic Personality
Disorder
Disorder Anankastic personality disorder: • characterised by feelings of excessive doubts, preoccupation with details, perfectionism interfering with task completion, excessive conscientiousness and pedantry, rigidity
• intrusion of insistent and unwelcome thoughts or impulses that do not attain the severity of an obsessive­compulsive disorder Personality (disorder):
• compulsive
• obsessional
• obsessive­compulsive F60.6 Anxious (Avoidant)
Personality Disorder
Personality Anxious (avoidant) personality disorder: • characterized by persistent and pervasive feelings of tension and apprehension, preoccupation with being criticized or rejected by others, avoidance of social or occupational activities because of fears of disapproval or rejection F60.7 Dependent Personality
Disorder
Disorder Dependent personality disorder: • characterized by pervasive passive reliance on other people to make one's major and minor life decisions, great fear of abandonment, feelings of helplessness and incompetence, passive compliance with the wishes of elders and others, and a weak response to the demands of daily life
• lack of vigour may show itself in the intellectual or emotional spheres
• there is often a tendency to transfer responsibility to others. Personality (disorder):
•
•
•
• asthenic
inadequate
passive
self­defeating F62 Enduring Personality
Changes, not Attributable to Brain
Damage and Disease
Damage
F62
F62.0
F62.1
F62.8
F62.9 Enduring personality changes, not attributable to brain damage and disease Enduring personality change after catastrophic experience Enduring personality change after psychiatric illness Other enduring personality changes Enduring personality change, unspecified F62.0 Enduring Personality Change
after Catastrophic Experience
after Enduring personality change after catastrophic experience: • presentfor at least two years, following exposure to catastrophic stress
• characterized by a hostile or distrustful attitude toward the world, social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of "being on edge" as if constantly threatened, and estrangement.
• enduring personality change after psychiatric illness (mostly schizophrenia) may appear due to the traumatic experience of suffering from a severe psychiatric illness Personality change after: •
•
• concentration camp experiences
disasters
prolonged: captivity with an imminent possibility of being killed
exposure to life­threatening situations such as being a victim of terrorism • torture Treatment of Personality Disorders
Treatment Psychotherapy • people who complain about lack of confidence and have difficulties in making relationships are usually motivated for psychotherapy
• in emotionally unstable and dissocial personalities disorders the patient should recognize the situations which provoke his/her pathological reactions and should manage to avoid them
• psychotherapy of personality disorders is a very difficult task and to reach a partial effect requests patient’s thorough motivation Pharmacotherapy helps in emotional disorders • anxiolytics and SSRI antidepressants suppress anxiety and depressive symptoms
• lithium and other thymoprofylactics (carbamazepin, valproic acid) reduces mood fluctuation and aggressive tendencies F63 Habit and Impulse Disorders
F63
F63
F63.0
F63.1
F63.2
F63.3
F63.8
F63.9 Habit and impulse disorders Pathological gambling Pathological fire­setting (pyromania)
Pathological stealing (kleptomania)
Trichotillomania Other habit and impulse disorders Habit and impulse disorder, unspecified F63.0 Pathological Gambling
F63.0 Pathological gambling: • consists of frequent, repeating episodes of gambling which dominate patient’s life leading to social, occupational, material and family detriment
• it means an intense urge to gamble and preoccupation with ideas of the act of gambling which finally leads to large debts, criminal acting, loss of job and family Psychotherapy and regime therapy is alike the treatment of alcoholism (group psychotherapy — Anonymous gamblers, 12­steps psychotherapy, family therapy, etc.). F63.1 Pathological Fire-Setting
(Pyromania)
(Pyromania) Pyromania: • characterized by attempts at, or acts of setting fire to property or objects without any apparent motive
• connected with an intense interest in watching fires burn and feelings of increasing tension before the act, and intense excitement immediately after it has been carried out F63.2 Pathological Stealing
(Kleptomania)
(Kleptomania) Kleptomania ­ pathological stealing: • means that the patient suffers from intense impulses to steal objects that are not acquired for personal use or monetary gain
• this disturbance may appear within the symptomatology of eating disorders F63.3 Trichotillomania
F63.3 Trichotillomania: • characterized by noticeable hair loss due to a recurrent failure to resist impulses to pull out hairs F64 Gender Identity Disorders
F64
F64
F64.0
F64.1
F64.2 Gender identity disorders Transsexualism Dual­role transvestism Gender identity disorder of childhood F64.8 Other gender identity disorders F64.9 Gender identity disorder, unspecified For details see lecture Paraphilias. F65 Disorders of Sexual
Preference
Preference
F65
F65.0
F65.1
F65.2
F65.3
F65.4
F65.5
F65.6
F65.8
F65.9 Disorders of sexual preference Fetishism Fetishistic transvestism Exhibitionism Voyeurism Paedophilia Sadomasochism Multiple disorders of sexual preference Other disorders of sexual preference Disorder of sexual preference, unspecified For details see lecture Paraphilias. F66
F66
F66.0
F66.1
F66.2
F66.8
F66.9
F68
F68.0
F68.1
F68.8
F69 Psychological and behavioural disorders associated with sexual development and orientation Sexual maturation disorder Egodystonic sexual orientation Sexual relationship disorder Other psychosexual development disorders Psychosexual development disorder, unspecified Other disorders of adult personality and behaviour Elaboration of physical symptoms for psychological reasons Intentional production or feigning of symptoms or disabilities, either physical or psychological (factitious disorder)
Other specified disorders of adult personality and behaviour Unspecified disorder of adult personality and behaviour For details see lecture Paraphilias. The Law and Ordinary
Psychiatric Practice
Psychiatric Consent to medical treatment and to hospitalization ­ the patient should be informed about the treatment procedures and probable side­effects of them to be able to give „informed consent”.
Compulsory admission and treatment (“admission without consent”) is realized in emergency situations (suicidal attempts, aggressive behaviour due to mental disorder towards other people, disorders of behaviour endangering patient’s life). A compulsory admission should be reported to the local court within 24 hours; the court will decide within one week’s period whether the admission has been justified. Civil Law
Civil Testamentary capacity means that the individual is able to make a valid will. If there are some doubts about it, the validity of the testament can be challenged. The testator should be of „sound disposing mind” at the time of making it.
Four legal criteria: 1. the testator understands what a will is and what its consequences are
2. he knows the nature and extent of his property
3. he knows the names of close relatives and can assess their claims to his property
4. he is free from an abnormal state of mind. Serious and persistent mental disorders cause incapacity of making decisions; the court appoints a guardian who is looking after patient’s affairs. Criminal Law
Criminal A person who committed a crime in a state of mental disorder undergoes psychiatric examination: • the expert gives a report on the mental state of the offender at the time of crime and on his/her present mental condition • according to the report conclusions the court decides about diminished or missing responsibility of the offender and about fitness to plead
• if the offender is dangerous to other people on the ground of medical reasons the court can order compulsory treatment (psychiatric, antialcoholic, antitoxicomanic, sexuological) Psychiatric (Court) Report
Psychiatric Psychiatric report is worked out at the request of police, prosecutor, counselor, court or any part of the action in court. It includes
•
•
•
•
•
• the data of the examination
family and personal history
the account of the crime given by the accused person
present mental state
mental state at the time of the crime
fitness to plead Finally the expert replies the questions put by the court.
The court takes account of a report as of any other proof; it means that it is not binding for its final decision. ...
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